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SAN JOAQU- - COUNTY ENVIRONMENTAL HEALT" DEPARTMENT SERVICE REQUEST Type of Business or Property COMMENTS: i FACILITY ID # EMPLOYEE #: SERVICE REQUEST # n. EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: OWNER I OPERATOR Fee Amount: CHECK If BILLING ADDRESS Payment Date Payment Type Invoice # FACILITY NAME 1 SITE ADDRESS ��{ 1 J . V l b / , Sn a p 1 ,�,\„j W"l I `' (&. ) u o Street Number Direction Street Name CI ZI Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CIN STATE ZIP ' PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS l PHONE # EXT. BUSINESS NAME L I I' ki M HOME or MAILING ADDRESS FAX# CITY STATE CE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. ,1 APPLICANT'S SIGNATURE: ax;w DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT �1P i fp,-CL }n 1r e IfAPPLICANT is not the BILLINGPARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data, and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as itis available and at the same time it is .: rinrt 4n mP nr ) rPtIYPCPrI}',lit\/P TYPE OF SERVICE REQUESTED: d S 1 COMMENTS: i ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: PI E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)